More prenatal care, but clinical outcomes mostly unchanged

Action Points

Note that this analysis of administrative data suggests that, after institution of the Affordable Care Act, young mothers were slightly more likely to have prenatal care.

The analysis also suggests some cost-shifting of care for young mothers from Medicaid to private insurance.

Young mothers on their parents' health insurance under the Affordable Care Act (ACA) seemed to have increased private insurance payment for birth and increased use of prenatal care compared with prior to the ACA, researchers found.

In adjusted analyses, dependent coverage was linked with a 1.9 percentage-point increase (95% CI, 1.6-2.1, P<0.001) in private insurance payment for birth for women, ages 24 to 25, after the implementation of the ACA, reported Jamie R. Daw, and Benjamin Sommers, MD, PhD, both of Harvard Medical School in Boston.

Moreover, the ACA was linked to a 1.0 percentage-point increase (95% CI 0.7-1.2, P<0.001) in early prenatal care, which remained significant even after adjusting for payment for birth, the authors wrote in the Journal of the American Medical Association.

Daw and Sommers also found a "modest" reduction in preterm birth of 0.2 percentage points (95% CI -0.03 to -0.03, P=0.02), but it was no longer significant after adjusting for payment for birth. The authors found no significant changes in cesarean section delivery, low birth weight, or NICU admission.

The ACA allowed young adults to remain on their parents' health plans until age 26, and a third of U.S. births are to women ages 19-25, the authors said. They added that while prior research studied this "dependent coverage provision" in regards to increased preventive care and improved self-reported health, only one study found an increase in privately insured birth and a decline in Medicaid-paid births among unmarried women.

"Insurance changes among reproductive-age and pregnant women associated with the provision could lead to improvements in prenatal care use and birth outcomes," the authors wrote.

They examined individual-level public-use natality files, and limited their sample to only states that adopted the 2003 revised U.S. Standard Certificate of Live Birth each year. This study looked at two time periods -- 2009, prior to the enactment of the ACA, and 2011-2013, after enactment of the dependent coverage provision.

The authors noted that in 2014, Medicaid and marketplace expansions took effect, and while dependent coverage was not technically mandated until September 2010, "some insurers voluntarily implemented it earlier in 2010," hence its exclusion from the data set.

Researchers compared data from two sets of women: 1,379,005 births among women ages 24 to 25 (the exposure set) and 1,551,192 births among women ages 27 to 28 (the control set). They noted that prior to the ACA, the exposure group had a younger paternal age and a higher portion of women who were Hispanic, black, unmarried, or without post-secondary education versus controls.

In addition to an increase in private insurance payments, adjusted analyses found a 1.4 percentage-point decline (95% CI -1.7 to -1.2, P<0.001) in Medicaid payment. There was also a 0.4 percentage-point increase (95% CI 0.2-0.6) in adequate prenatal care, but after adjusting for payment for birth, the association was no longer significant, the authors said.

They noted that given the "relatively small coverage and utilization changes associated with the policy," the small changes in birth outcomes were not surprising, and were similar to prior research. They suggested that further research should examine other aspects of the law on insurance coverage in pregnancy, including "access to care, maternal outcomes, and both short-term and long-term children's health outcomes."

Study limitations included the fact that a difference-in-differences analysis "relies on the assumption that the trend after implementation for the control group is a valid counterfactual for what would have been observed in the exposure group, if not for the policy," the authors said. They also pointed out that use of narrow age bands, and that the policy may have had a different impact on younger age women.

Daws disclosed no relevant relationships with industry.

Sommers disclosed support from AHRQ, Commonwealth Fund, and Robert Wood Johnson Foundation. John Hopkins University, University of Pennsylvania, University of Chicago,MetroHealth/CaseWestern University, AcademyHealth, American Economic Association, America's Health Insurance Plan, Institute for Medicaid Innovation, and Milbank Memorial Fund, and a relevant relationship with the U.S. Department of Health and Human Services (September 2011-June 2016).

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.